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Psychosis and schizophrenia in children and young people
Short Text
Introduction
This pathway covers the recognition and management of psychosis and schizophrenia in children and young people under 18 years by primary, community, secondary, tertiary and other health and social care professionals, including professionals in CAMHS and early intervention in psychosis services. The term 'psychosis' refers to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder and delusional disorder.
Psychosis alters a person's perception, thoughts, mood and behaviour. Symptoms are usually divided into 'positive symptoms', including hallucinations (perception in the absence of any stimulus) and delusions (fixed or falsely held beliefs), and 'negative symptoms' (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect). Children and young people who develop psychosis will have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their circumstances and stage of development.
Psychosis is commonly preceded by a prodromal period, lasting up to 12 months, in which behaviour and experience are altered. Changes include the emergence of transient and/or attenuated psychotic symptoms, such as hallucinations and/or delusions with associated impaired functioning. The child or young person may also become socially withdrawn or suspicious. Most children and young people with transient or attenuated psychotic symptoms do not develop psychosis or schizophrenia, but they do appear to be at higher risk of developing psychosis or schizophrenia up to 10 years after onset of symptoms.
The prevalence of psychotic disorders in children and young people aged 5–18 years is about 0.4% (the estimate for all ages and populations in the UK is 0.7%). There is a worse prognosis when onset is in childhood or adolescence. Although about one-fifth of children and young people with schizophrenia have only mild impairment, one-third have severe impairment that needs intensive social and psychiatric support. There can be major detrimental effects on personal, social, educational and occupational functioning, placing a heavy burden on them and their parents and carers.
Although the mainstay of treatment for psychosis and schizophrenia has been antipsychotic medication, there is limited evidence of its efficacy in children and young people. There are also concerns that children and young people are more sensitive than adults to the potential adverse effects of antipsychotics, including weight gain, metabolic effects and movement disorders. A number of psychological interventions, including family intervention, CBT and arts therapies, have been used but evidence of efficacy in children and young people is lacking and provision is variable.
Source guidance
The NICE guidance that was used to create the pathway.
Psychosis and schizophrenia in children and young people: recognition and management. NICE clinical guideline 155 (2013)
Aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years. NICE technology appraisal guidance 213 (2011)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Assessment tools
The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Costing support
Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Supporting information
Glossary
Cognitive behavioural therapy.
Electrocardiogram.
Child and adolescent mental health services.
Glycosylated haemoglobin.
British national formulary.
British national formulary for children.
Summary of product characteristics.
Child or young person
Child or young person
General principles of care for children and young people with psychosis and schizophrenia
View the 'General principles of care for children and young people with psychosis and schizophrenia' pathPresentation in primary care
Presentation in primary care
Presentation in primary care
Possible psychosis
When a child or young person experiences transient or attenuated psychotic symptoms or other experiences suggestive of possible psychosis, refer for assessment without delay to a specialist mental health service such as CAMHS or an early intervention in psychosis service (14 years or over).
First episode psychosis
Urgently refer all children and young people with a first presentation of sustained psychotic symptoms (lasting 4 weeks or more) to a specialist mental health service, either CAMHS (up to 17 years) or an early intervention in psychosis service (14 years or over), which includes a consultant psychiatrist with training in child and adolescent mental health.
Antipsychotic medication in children and young people with a first presentation of sustained psychotic symptoms should not be started in primary care unless it is done in consultation with a consultant psychiatrist with training in child and adolescent mental health.
See also the recommendations on children and young people in crisis and challenging behaviour in this pathway.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAssessment in specialist mental health services
Assessment in specialist mental health services
Assessment in specialist mental health services
Possible psychosis
Carry out an assessment of the child or young person with possible psychosis, ensuring that:
- assessments in CAMHS include a consultant psychiatrist
- assessments in early intervention in psychosis services are multidisciplinary
- where there is considerable uncertainty about the diagnosis, or concern about underlying neurological illness, there is an assessment by a consultant psychiatrist with training in child and adolescent mental health.
If a clear diagnosis of psychosis cannot be made, monitor regularly for further changes in symptoms and functioning for up to 3 years. Determine the frequency and duration of monitoring by:
- the severity and frequency of symptoms
- the level of impairment and/or distress in the child or young person, and
- the degree of family disruption or concern.
If discharge from the service is requested, offer follow-up appointments and the option to self-refer at a later date. Ask the GP to continue monitoring changes in mental state.
First episode psychosis
Ensure that children and young people with first episode psychosis receive a comprehensive multidisciplinary assessment. The assessment should address the following domains:
- psychiatric (mental health problems, risk of harm to self or others, alcohol consumption and prescribed and non-prescribed drug history)
- medical, including medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis
- psychological and psychosocial, including social networks, relationships and history of trauma
- developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions)
- physical health and wellbeing (including weight and height, and information about smoking, diet and exercise, and sexual health)
- social (accommodation, culture and ethnicity, leisure activities and recreation, carer responsibilities [for example, of parents or siblings])
- educational and occupational (attendance at school or college, educational attainment, employment and functional activity)
- economic (family's economic status).
Carrying out the assessment
When carrying out an assessment:
- ensure there is enough time for:
- the child or young person and their parents or carers to describe and discuss their problems
- summarising the conclusions of the assessment and for discussion, with questions and answers
- explain and give written material in an accessible format about any diagnosis given
- give information about different treatment options, including pharmacological and psychological interventions, and their benefits and side effects, to promote discussion and shared understanding
- offer support after the assessment, particularly if sensitive issues, such as childhood trauma, have been discussed.
Offering a second opinion
If the child or young person and/or their parent or carer is unhappy about the assessment, diagnosis or care plan, give them time to discuss this and offer them the opportunity for a second opinion.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeCare planning in specialist mental health services
Care planning in specialist mental health services
Care planning in specialist mental health services
Develop a care plan with the parents or carers of younger children, or jointly with the young person and their parents or carers, as soon as possible, and:
- include activities that promote physical health and social inclusion, especially education, but also employment, volunteering and other occupations such as leisure activities
- provide support to help the child or young person and their parents or carers realise the plan
- give an up-to-date written copy of the care plan to the young person and their parents or carers if the young person agrees to this; give a copy of the care plan to the parents or carers of younger children; agree a suitable time to review it
- send a copy to the primary healthcare professional who made the referral.
Support children and young people to develop strategies, including risk- and self-management plans, to promote and maintain independence and self-efficacy, wherever possible. Incorporate these strategies into the care plan.
If the child or young person is at risk of crisis, develop a crisis plan with the parents or carers of younger children, or jointly with the young person and their parents or carers, and with their care coordinator. The plan should be respected and implemented, incorporated into the care plan and include:
- possible early warning signs of a crisis and coping strategies
- support available to help prevent hospitalisation
- where the child or young person would like to be admitted in the event of hospitalisation
- definitions of the roles of primary and secondary care professionals and the degree to which parents or carers are involved
- information about 24-hour access to services
- the names of key clinical contacts.
Routinely monitor for other coexisting mental health problems, including depression and anxiety, and substance misuse, particularly in the early phases of treatment.
Access to education
For children and young people with first episode psychosis who are unable to attend mainstream school or college, facilitate alternative educational input in line with their capacity to engage with educational activity and according to their individual needs, with an ultimate goal of returning to mainstream education, training or employment.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTreatments for children and young people with possible psychosis, psychosis and schizophrenia
View the 'Treatments for children and young people with possible psychosis, psychosis and schizophrenia' pathPromoting recovery and providing possible future care for children and young people with psychosis or schizophrenia
View the 'Promoting recovery and providing possible future care' pathTransfer and discharge
Transfer and discharge
Transfer and discharge
Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in children and young people with psychosis or schizophrenia and their parents or carers. Ensure that:
- such changes, especially discharge and transfer from CAMHS to adult services, or to primary care, are discussed and planned carefully beforehand with the child or young person and their parents or carers, and are structured and phased
- the care plan supports effective collaboration with social care and other care providers during endings and transitions, and includes details of how to access services in times of crisis
- when referring a child or young person for an assessment in other services (including for psychological interventions), they are supported during the referral period and arrangements for support are agreed beforehand with them.
Continuing psychological interventions after discharge
When psychological interventions, including arts therapies, are started in the acute phase (including in inpatient settings), the full course should be continued after discharge without unnecessary interruption.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeChildren and young people in crisis and challenging behaviour
View the 'Children and young people in crisis and challenging behaviour' pathPaths in this pathway
- General principles of care for children and young people with psychosis and schizophrenia
- Treatments for children and young people with possible psychosis, psychosis and schizophrenia
- Choosing and delivering interventions for psychosis and schizophrenia
- Promoting recovery and providing possible future care
- Children and young people in crisis and challenging behaviour
Pathway created: January 2013 Last updated: January 2013
Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.